LA Times wrote a piece titled “Amazon Care may be to healthcare what Amazon Prime is to shopping”.

Now that is quite a prediction! Amazon currently handles a lot of the Internet’s e-commerce, almost 50% at time of writing.

Last year, Amazon joined Berkshire Hathaway and JP Morgan Chase with the intention of overhauling the US Healthcare system.

Currently, Amazon Care is piloting its virtual primary care clinic with its employees. In other words, Amazon is getting into telehealth.

An in-app video visit with a doctor, nurse practitioner, or registered nurse … for advice, answers, diagnosis, treatment or referrals. Employees will have an option to see a health provider via a mobile app or website, and they can text a nurse on any health topic in minutes.

They are likely to expand into the pharmaceutical world with medication delivery, as they already have a lot of the infrastructure, at least logistically. Amazon processes a lot of data, based on all of their services including their e-commerce, recent acquisition of Whole Foods, and its streaming services to name a few. I agree with the author that if any company has a shot of making a profound impact on the introduction of Telehealth, it would be Amazon. They have a wide userbase, good customer support, strong company image, and a lot of experience handling high traffic business.

AOTA has a page on dedicated to Telehealth and it is definitely worth checking out. Personally, I am not against Telehealth because it can offer many benefits:

  • Convenient access without physically visiting an office.
  • Can provide healthcare services to rural areas, which may have limited resources or patients may have to travel far for an appointment.
  • Quick response time to ask questions and have them answered.

Although this post may not reach millions or even hundreds, I feel a strong obligation to share my opinion on what needs to be done, the steps to take, and the precautions – for any company, not just Amazon, to take when considering and implementing telehealth.

Firstly, telehealth can be thought of as assistive technology. Therefore, it may not be the right tool for everyone. Can the client successfully benefit from and be able to properly use the technology? For example, while smartphone developers have done a phenomenal job with access, including the implementation of accessibility features for the general public, there are still many users who are unable to utilize a smartphone.

Privacy & Confidentiality

There are many levels and vectors of attack. Amazon could code and implement the most perfect system for Amazon Care, but a user’s device could be compromised on the other end. Any digital correspondence would, therefore, be snooped on by a third party. If you take “hacking” out of the equation, humans will continue to pose a threat to privacy and confidentiality, as they can be the weakest link, despite how strong the security in technology can be. I have been guilty of this myself and wrote some of my passwords down in cleartext. All it could take is an Amazon employee (who may have the best of intentions), or even an intermediate healthcare provider to fall prey to phishing or social engineering, thus leaking all of the user’s private health data to the Internet.

While I believe big companies will likely be responsible in this regard, startup companies, entrepreneurs, and up and coming coders have a responsiblity to write good code, use best practices, and have their code audited. Closed source software has its benefits, but in healthcare, I am not so sure if that is the best. Take for example, Android vs IOS. Google’s Android is climbing the ranks in security due to its open-sourced nature and the bounty for finding exploits/hacks is much higher for Apple, arguably, because Android currently has less vulnerabilities than Apple’s IOS.

Opinion: In general, I believe that the public needs to be educated on the use of technology and the importance of security and privacy. It should be taught in schools at an early age, and continued to be reinforced, because it takes practice, just like personal finance or religion/faith.

Only now is my workplace providing education modules on topics such as malware, ransomware, key loggers, phishing attacks, etc. And what do I still see every day at work? Computers logged on with patient information left unattended for sometimes, very long moments of time. I try my best to educate my colleagues on the risks involved.

Therefore,

Opinion: Healthcare providers using Telehealth will need to be educated on all the risks involved before they should be allowed to provide any services on the topics that are mentioned.

Wrapping this up, companies need to implement the best practices, with continued security updates, to safeguard users privacy and confidentiality. Data should be encrypted when possible, end-to-end, with open-source code that can be audited by the public. Will open source happen with companies such as Amazon, probably not.

Accessibility

A use case that comes to mind is closed captioning. For a client who is hard of hearing, will Telehealth provide a readout of what the other party is saying so that there are no barriers to care? How can this be done on a “live” basis? Although cloud computing has been developing at a very rapid pace, there are still many barriers to the accuracy of the content compared to what is transcribed “by hand” by a human. One wrong word generated by an algorithm that is mistaken in the medical world can have a very harmful impact on the client.

Opinion: Telehealth will need to have accessibility features for the visually, hearing, and physically impaired.

Currently, I encounter many accessibility issues with video translator or even telephone translation. They are often hard to hear, with the volume not being loud enough. There is a delay due to the use of Wifi and other factors, which create a long time between responses that make the therapy session not therapeutic. Sometimes, the translator cannot hear the patient on the other end. Clients with cognitive deficits have difficulty talking to a screen, or they may get confused when the translator speaks English so that I can comprehend. These accessibility issues need to be overcome to provide quality patient care if it is to replace traditional face-to-face methods.

Side note: as an OT, I personally am not a fan of video translators because they are not as easy to move around and carry like a phone, require more attention when mobilizing a patient, which can pose additional fall risks, and I just think it is awkward having a video translator watch my patient perform their ADLs. Yes, I can “mask” or “turn off” the patient’s video, but that totally defeats the purpose of video translation in the first place. If your company is considering implementing video translators, consider these factors! They definitely should not be a replacement to your current system, but an addition or an alternative.

Can the provider get a clear clinical picture of the client without physically being in the room? While this may be appropriate for some interventions such as client interview for their past medical history or current chief complaint, how can they assess the patient’s physically? Would the client take a picture or show them on video? Would the lighting of the client’s environment even be good enough to see on the other end? The provider cannot palpate or auscultate the client through Telehealth. Poor/degraded picture quality from the client’s camera or image artifacts due to video compression could also compromise patient care. What if the patient is not physically able to show the provider due to deficits, e.g. hemiparesis or lack of fine motor control?

Ethics

How will telehealth handle consent, rights of the patients, ethics in care, cultural barriers, and so on? Personally, I would not feel very comfortable taking a picture of myself or showing on video compared to in-person to a doctor or other healthcare provider. How would telehealth address this? How will they obtain consent? By me initiating a call and checking a box? Will the general public understand the implications of this? Will sessions be video/audio recorded or there be a record of this on some server someplace? How long will it be available and will it be deleted?

Costs

How will be reimbursement work?

  • Who gets paid and how much?
  • Will it be subscription based, session based, or some other system?
  • Who will have access, and how does the queue operate to ensure fair access and not “privileged” access? Can users have access to faster access if they pay more? Is that ethical?

What do you think of all this?